Sturbridge Orthodontics Practice Policies

Patient First Name:
Last Name:
Financially Responsible Person:
THE FINANCIAL CONTRACT is in effect for Orthodontic treatment until contract paid in full regardless of length of treatment or completion of appointments, or patient compliance with the necessary appointments.
IF TREATMENT IS EXTENDED beyond 36 months, due to lack of cooperation or traumatic injury, there will be an extra monthly charge until the braces are removed. The monthly charge is now $150.00, but may differ in the future. If there is excessive breakage of the braces, or loss of removable appliances, retainers, et cetera, there may be additional repair or replacement charges, to be determined at that time.
IN THE EVENT OF A DECLINED AUTOMATIC DRAFT, a second attempt will be scheduled for 5 days after the draft date. The responsible party must contact the office within 10 days of the scheduled due date or failure to do so may result in a $25.00 late fee.
IF SERVICES ARE TERMINATED for any reason before completion of treatment, the account will be adjusted and a just settlement will be determined based on the amount of treatment completed.
SERVICES PROVIDED BY OTHERS, general dentist, oral surgeon, periodontist etc., outside of this orthodontic practice are not part of the treatment fee.
By typing your name below, you acknowledge it as an electronic signature.

E-SIGNATURE OF FINANCIALLY RESPONSIBLE PERSON:
Date:
By typing your name below, you acknowledge it as an electronic signature.
E-SIGNATURE ON FILE FOR INSURANCE
I hereby grant consent to Sturbridge Orthodontics for the taking of x-rays, photographs and other necessary records before, during and after treatment, and to the use of same by this practice for scientific papers and demonstrations, and/or social media, marketing and office events."
  • The insurance balance provided at exam is an estimate of coverage. The actual insurance benefit will be determined by your insurance provider once they are billed at the start of treatment.
  • If there are any changes or updates to my policy, I will notify Sturbridge Orthodontics office to update my contract.
  • If there is a termination of coverage, or account balance is not paid directly to the practice by the insurance company, the unpaid balance becomes my responsibility. If insurance covers all or part of the fee, it must be paid directly to the practice (or to the policy holder, if arranged).
  • I understand the insurance balance is not paid in one installment. I must maintain my benefits throughout the course of treatment for the full estimated insurance benefit to be received.
By typing your name below, you acknowledge it as an electronic signature.
E-SIGNATURE OF FINANCIALLY RESPONSIBLE PERSON:
Date:
By typing your name below, you acknowledge it as an electronic signature.
E-SIGNATURE OF RESPONSIBLE PERSON:
Date: